Original Investigation |

Utilization and Outcomes of Inpatient Surgical Care at Critical Access Hospitals in the United States

Adam J. Gadzinski, MD, MS1; Justin B. Dimick, MD, MPH2; Zaojun Ye, MS1; David C. Miller, MD, MPH1
[+] Author Affiliations
1Department of Urology, University of Michigan Health System, Ann Arbor
2Department of Surgery, University of Michigan Health System, Ann Arbor
JAMA Surg. 2013;148(7):589-596. doi:10.1001/jamasurg.2013.1224.
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Published online

Importance  There is a growing interest in the quality and cost of care provided at Critical Access Hospitals (CAHs), a predominant source of care for many rural populations in the United States.

Objective  To evaluate utilization, outcomes, and costs of inpatient surgery performed at CAHs.

Design, Setting, and Patients  A retrospective cohort study of patients undergoing inpatient surgery from 2005 through 2009 at CAHs or non-CAHs was performed using data from the Nationwide Inpatient Sample and American Hospital Association.

Exposure  The CAH status of the admitting hospital.

Main Outcomes and Measures  In-hospital mortality, prolonged length of stay, and total hospital costs.

Results  Among the 1283 CAHs and 3612 non-CAHs reporting to the American Hospital Association, 34.8% and 36.4%, respectively, had at least 1 year of data in the Nationwide Inpatient Sample. General surgical, gynecologic, and orthopedic procedures composed 95.8% of inpatient cases at CAHs vs 77.3% at non-CAHs (P < .001). For 8 common procedures examined (appendectomy, cholecystectomy, colorectal cancer resection, cesarean delivery, hysterectomy, knee replacement, hip replacement, and hip fracture repair), mortality was equivalent between CAHs and non-CAHs (P > .05 for all), with the exception that Medicare beneficiaries undergoing hip fracture repair in CAHs had a higher risk of in-hospital death (adjusted odds ratio = 1.37; 95% CI, 1.01-1.87). However, despite shorter hospital stays (P ≤ .001 for 4 procedures), costs at CAHs were 9.9% to 30.1% higher (P < .001 for all 8 procedures).

Conclusions and Relevance  In-hospital mortality for common low-risk procedures is indistinguishable between CAHs and non-CAHs. Although our findings suggest the potential for cost savings, changes in payment policy for CAHs could diminish access to essential surgical care for rural populations.

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Figure 1.
Hospitals Performing at Least 5 Inpatient Surgical Specialty Procedures in 1 Year

Proportion of hospitals performing at least 5 inpatient surgical specialty procedures in 1 year according to Critical Access Hospital (CAH) designation. P < .001 for all specialty comparisons.

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Figure 2.
Adjusted Hospital Costs Associated With Surgical Admissions According to Critical Access Hospital (CAH) Designation

A, All patients. B, Patients with Medicare as primary payer. C, Elective admissions. Total costs were calculated from total charges, hospital-specific cost-to-charge ratios, and principal diagnosis adjuster. Costs were adjusted for patient variables, length of stay, and rural or urban location of admitting hospital. Error bars indicate 95% CIs. P < .001 for all procedure comparisons. CRC indicates colorectal cancer.

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